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(Nurses Educational Specialist Trainer)

Tel # (082) 271-4319
CARE OF THE CLIENTS WITH PSYCHOSOCIAL ALTERATIONS MENTAL HEALTH NURSING PSYCHIATRIC NURSING An interpersonal process whereby the nurse assist an individual, family or community, to [promote mental health, to prevent or cope with the experience of mental illness and suffering and if necessary, to find meaning in these experiences. GENERAL CONCEPTS OF MENTAL HEALTH AND ILLNESS MENTAL HEALTH A state of emotional, psychological and social wellness. - Satisfying interpersonal relationships. - Effective behavior and coping. - A positive self-concept - Emotional stability. State of adjustment with maximum effectiveness and satisfaction. Fundamental for personal happiness. Contentment, achievement, optimism and hope. Absence of mental and behavioral disorder or disturbances. MENTAL ILLNESS Ones view of an act The reaction of others Overall cultural context in which the acts occur Often a matter of adjustment not a matter of a act BEHAVIOR It refers to the way an organism responds to a stimulus It is purposeful It is observable, recordable and measurable VARIETIES OF BEHAVOIR Reflex action Goal-directed behavior - Needs and goals - The need-satisfaction sequence is a pattern established very early in life in relation to biologic needs which are present at birth Behavior as a response to frustration NEEDS Organismic condition which exists within the individual which demands certain activities. A state of tension which disrupts ones equilibrium. Produces a relative degree of discomfort. From metabolic processes, relationship with the environment and symbolic behaviors.

Maslows Hierarchy of Needs

Self actualization Self-esteem Love and belongingness Safety

Basic physiologic needs PERSONALITY DEVELOPMENT PERSONALITY Individuals internal and external adjustment to life. Integration of behaviors that is lifelong. Integration of traits which can be investigated or described in order to render and account of the unique quality of an individual. All that an individual is, feels and does consciously and unconsciously. In part determined by ones genetically transmitted organic endowment and in part by ones life experiences. FREUDS PSYCHOSEXUAL THEORY Postulated that the mind consist roughly of three overlapping divisions: 1. Conscious 2. Preconscious 3. Unconscious Psychoanatomically, personality has three basic parts whose internal conflict and balance produce behavior: 1. Id 2. Superego 3. Ego Personality development is equated to psychosexual development (libido). Maturation of the sexual instinct is the last step in the maturation of emotional development. Each stages interests become permanent parts of the personality. The stages: - Oral - Anal - Phallic - Latency - Genital ERICKSONS PSYCHOSOCIAL THEORY Psychosocial maturity Everyone goes thru a developmental stage featured by a developmental task that must be successfully completed if the succeeding tasks are being resolved in turn. There is interplay between the positive and negative outcomes inherent in each task. Womb to tomb Stages are: - Sensory infancy ; Trust vs. Mistrust - Muscular toddler ; Autonomy vs. Shame and doubt - Locomotor preschool ; Initiative vs., Guilt - Latency school age ; Industry vs. Inferiority - Adolescent teeanage years ; Identity vs. Role diffusion - Young adulthood Intimacy vs. Isolation - Adulthood Generativity vs. Stagnation - Maturity elderly ; sense of Integrity vs. Despair SULLIVANS INTERPERSONAL THEORY Personal interrelationships Self-image and self concept organizes behavior and is built as a result of his experience with significant other persons and their reflected appraisals Emphasizes social factors Maturation of inter-relational skills leads to personality maturation Stages are: - Infancy - Childhood - Juvenile - Preadolescence - Early adolescence

Late adolescence

PIAGETS COGNITIVE THEORY Motor activities involving concrete objects results in the development of mental functioning (learning) New operation building on already existing ones Increasing integration and coordination Maximal learning through the process of contemplative recognition Stages of cognitive development are: - Sensorimotor - Preoperational - Concrete operational - Formal operations KOHLBERGS MORAQL DEVELOPMENT Moral development depends primarily on cognitive development Moral development goes hand in hand with thinking and judgement Stages are: - Pre conventional punishment and obedience - Conventional social system and conscience - Post-conventional universal ethical principle PERSONALITY DEVELOPMENT 1. Development is a continuum 2. Behavior has meaning and is not determined by chance. 3. All behaviors should be goal-directed 4. The unconscious plays an active role in determining behavior. 5. The early years of life are extremely important for personality development. ANXIETY A Central Concept STRESS A generalized non-specific response of the body to any demand whether positive or negative. Damaging or unpleasant forms of stress is distress. When stress is sufficiently great and reaches a point above the threshold of an individual, frustration results Response to Stress: Fight or flight mechanism Hans Selyes General Adaptation Syndrome Stage I - Stage or alarm reaction Stage II Stage of resistance Stage III Stage of exhaustion Anxiety A feeling of severe discomfit or dread that arises from within the individual in response to a threat, which is less visible and definable than fear, which has a visible object or trigger. Subjective experience detected by the objective behaviors that results from it. Emotional pain. Triggers autonomic relief behaviors aimed at eliminating anxiety. Contagious; communicated from one person to another. Caused by actual or anticipated threats to basic needs (biologic, safety, etc.) Manifestation of Anxiety Physiologic - Tachycardia - Elevated BP - Increased sweating - Muscle tension - Frequency of urination

Tremors Nausea, vomiting Sleep disturbance Lump in the throat Chest tightness

- Diarrhea Psychological - Restlessness - Apprehension - Anger or irritability - Withdrawal Intellectual / Cognitive - Forgetfulness - Preoccupational and blocking - Difficulty concentration - Failing to attend to detail - Decreased productivity / creativity - Diminished interest - Increased errors in judgement

Butterflies in the stomach Feeling or dread Tearfulness Feeling of being nervous

Levels of Anxiety Mild (+1) - Greater alertness to the environment occurs - People may feel more energetic and motivated - Behavior may be more efficient Moderate (+2) - Perceptual field begins to narrow - Shuts out periphery; focused on central concerns - (Selective Inattention) Severe (+3) - Perceptual fields is greatly reduced - People generally focus on small details but maybe unable to focus on the whole - Inability to focus on events and environment - Physiologic symptoms starts in moderate increases in severe Panic (+4) - Disruption of the perceptual field (Tunnel Vission) - Disorganization of the personality - Details maybe distorted - Inability to control the self or environment - Behavior purposeless and communication unintelligible - Complete immobility maybe present Nursing Interventions Panic level - Decrease anxiety, stimuli, pressure - Use kind, firm, simple directions - Use time-out (seclusion) - Intramuscular anti-anxiety medications needed Moderate level - Decreased anxiety by ventilation, crying or exercise - Refocus attention - Relate feelings and behaviors to anxiety - ]Oral anti-anxiety medications if indicated Mild level - Discuss the source of anxiety - Problem solving is done - Accept anxiety as natural; tolerate and learn from it Coping Responses Coping Mechanisms - Generally conscious methods of handling stress - Flexible, purposeful and involves choice - Oriented to the reality of the present situation - Allows for satisfaction in open, ordered and tempered ways

Defense Mechanisms - Generally unconscious methods of handling otherwise unmanageable anxiety - Rigid, compelled and inflexible - Essentially distorts the present situation - Allows for satisfaction only by indirect ways - Become counterproductive when used to the extreme Specific Defense Mechanisms 1. Repression 2. Suppression 3. Denial 4. Rationalization 5. Isolation 6. Symbolization 7. Compensation 8. Regression 9. Fixation CRISIS A for of severe stress Time-limited (4-6 weeks) and is precipitated by new or sudden situations. Pre-existing adaptive, alternative, resolving and coping mechanism are ineffective. Individual is in a state of disequilibrium. Stems from two major sources: - Stress event involving a fundamental loss - Threat to well-being of the person Has two forms: - Maturational/developmental crisis - Situational crisis Occurs in all ages Response is relative Ineffective resolution leads to future crisis

10. Sublimation 11. Displacement 12. Identification 13. Conversion 14. Reaction formation 15. Undoing 16. Introjection 17. Projection 18. Fantasy

Crisis Intervention Cope with an immediate problem - Does not go into cause or require insight The goal is to return the client into pre-crisis level of functioning Involves Clarifying present situations and problems, mobilize internal and external resources and teach new coping skills. Process of therapy includes: Establishing a nurse-client relationship Helping client to establish therapeutic goals Reinforcing that the relationship is time-limited Being active in facilitating immediate-problem solving Actively encourage client to express feelings and emotions regarding the crisis situation Help the client develop new coping mechanism Have the client take more responsibility in subsequent sessions THEORETICAL FRAMEWORK OF CARE Medical-Biological Model Behavior disturbance is an illness or defect Illness is located in the body, either a neurostructurral defects or biochemical alteration Disease entities can be diagnosed, classified and labeled Somatic therapies are used Psychoanalytical Model Behavioral disturbances stems from emotionally painful experiences Repressed feelings lead to unresolved and unconscious conflicts in the mind Defense mechanism develop which produces the disturbed symptoms Psychotherapy uncovers the roots of conflict through interviews in long-term therapy

Interpersonal Model Behavioral disturbances results from problematic interpersonal interactions Constructive interpersonal relationship is developed with the therapies Behavioral-Cognitive Model Clients need to eliminate faulty thought processes and self-defeating ideas Behavior can be modified by operant conditioning Behavior that is reinforced tends to be repeated and behavior that is ignored tends to be eliminated Response to behavior by therapists should be consistent Social Model Behavioral disturbances results from imbalance between stresses and support Too much stress and not enough support leads to social disorientation and disintegration; too much support, too little stress leads to social dependence, immobility and regression Treatment is aimed at restoring the balance Psychotherapeutic Model Therapeutic Nurse-Client Relationship Somatic Therapies - Psychopharmacology - Electroconvulsive therapies - Orthomolecular therapy Therapeutic Milieu - Therapeutic community - Environmental THERAPEUTIC NURSE-CLIENT RELATIONSHIP Therapeutic Use of Self Self awareness - Introspection - Discussion - Self-deiclosure Nurse Client Relationship It is the purposeful use of the nurses interpersonal skills directed towards growth producing outcomes for clients. Characteristics: Frequently informal and spontaneous and occurs in various health care and community settings. Maybe formalized with counseling or individual psychotherapy It is a professional and not a social relationship - concepts of transference and counter-transference Enabling Qualities of the Nurse Being available Demonstrating respect for the client Be competent Having a natural style based on flexible therapeutic goals Avoid negative judgement of clients Believing that all people have the capacity to grow and change Being able to empathize Phases Orientation Working Resolution Phases maybe preceded by a data gathering - Preorientation THERAPEUTIC COMMUNICATION COMMUNICATION The reciprocal exchange of information

Components - Sender, message, receiver, feedback and the context Models - Verbal, non-verbal, meta-communication Therapeutic Communication The process in which the nurse consciously utilizes the principles of communication in a goaldirected professional framework. Best responses should focus on the general guidelines General Guidelines * Open-ended questioning is best used * Here and now rather than the past * What rather than why * Orientation and presentation of reality * Actual client behaviors and nursing observations rather than giving inferences * Maintenance of biologic integrity * Nursing interventions rather than roles designated to other health team members * Sharing information and exploring alternatives rather than giving actual solutions Therapeutic Communications * Giving Information * Reflecting * Verbalizing Observations * Validating * Suggesting collaboration * Presenting Reality Non-therapeutic Communication Techniques Giving advice Rejection Directly agreeing or disagreeing with the client Directly expressing either approval or disapproval] Belittling the clients feeling Giving false reassurance Requesting or even demanding an explanation Defending Stereotyping responses Changing the topic SOMATIC THERAPIES Psychopharmacology Principles of Psychopharmacology A medication is selected based on the clients target symptoms Many psychotropic drugs must be given in adequate for a period of time before their full effect is realized The dosage of medication is often adjusted to the lowest dose effective for clients Elderly persons require lower dosages of medication to produce therapeutic effects and it may take longer for a drug to achieve its full therapeutic effect Psychotropic drugs are often decreased gradually rather than abruptly discontinued Follow-up care is essential to ensure compliance with the medication regimen, to make needed adjustments in dose and manage side effects. Anti-psychotics Classified either by chemical class, potency but more importantly by typicality Low-potency drugs causes more anticholinergic side effects whereas high-potency drugs causes more EPS Typical antipsychotics are the traditional drugs effective for positive symptoms but it results in several side effects. - chlorpromazine (Thorazine), thioridazine (Mellaril), haloperidol (Serenace), fluphenazine, trifluoperazine, loxapine Atypical Antipsychotics newer generation medications * * * * * * Giving Broad Openings General Leads Clarifying Focusing Offering Self Silence

Fewer extrapyramidal side effects (EPSE) Effective for negative symptoms No endocrine side effects (Prolactin increase) Potent antagonists of serotonin Clozapine (Clozaril, risperidone (Risperdal, olanzapine (Zyprexa), quetiapine (Seroquel), sertindole (Serlect), ziprasidone (Zeldox) Indicated for schizophrenia, acute mania, psychotic depression and drug induce psychosis Side Effects: 1. Extrapyramidal Symptoms (EPS) a. Acute Dystonia - Acute muscular rigidity and cramping, stiff thick tongue with difficulty swallowing; torticollis, opisthotonus or oculogyric crisis b. Pseudoparkinsonism - Stooped, stiff posture with mask-like facies, a festinating gait, cogwheel rigidity, drooling, bradykinesia, pill rolling tremors. c. Akathesia - Feeling of internal restlessness and inability to sit down 2. Neuroleptic Malignant Syndrome (NMS) Potentially fatal reaction to an antipsychotic drug; idiosyncratic Characterized by rigidity, high fever, autonomic instability and maybe confusion and muteness 3. Tardive Dyskinesia Syndrome of permanent involuntary movements of the tongue, facial and neck muscles, upper and lower extremities even truncal musculature Manifested as tongue-thrusting and protrusion, lip-smacking, blinking, grimacing

4. Anticholinergic effects
Orthostatic hypotension, dry mouth, constipation, urinary retention, photophobia and sensitivity 5. Endocrine changes Lactation in females; gynecomastia and impotence in males 6. Agranulocytosis For those taking clozapine Decrease in white blood cell hence prone to infections Nursing Interventions Check BP prior to administration Periodic liver function test and blood counts Observe for warning signs of adverse effects Note complaints of sore throat, nosebleed, rash, fever or other signs of infection Warn client that drowsiness may occur until tolerance is developed Teach the client to: - Avoid alcohol - Consult before taking other medications - Precautions to avoid skin damage from photosensitivity - High fiber diets, fluids, exercise and good oral hygiene Antiparkinson Drugs Given to control EPSEs in clients taking antipsychotic A balance between acetylcholine and dopamine is required for normal movement Balance is accomplished in three ways - Drugs used to increase dopamine 9Dopaminergic) - Drugs used to decrease the level of Ach - A combination of the above drugs Dopaminergic drugs include: - Carbidopa-levodopa (Sinemet), amantadine (Symmetrel), bromocriptine (Parlodel), pergolide (Permax),

selegilline (Eldepryl) Anticholinergics used are: - Benztropine (Cogentine), biperiden (Akineton), trihexyphenidyl (Artane), dephenhydramine (Benadryl) Common psychiatric side effects of dopaminergics - Confudion, hallucinations, delusions, depreddion, anxiety, agitation Common side effects of anticholinergics - Mydriasis and blurred vision, decreased secretions, nasal congestion, tachycardia, constipation Anti-depressants Classifications: 1. Tricyclic anti-depressants (TCAs) Blocks reuptake of serotonin and norepinephrine Includes imipramine (Tofranil), Amitriptyline (Elavil), Desipramine (Norpramin), amoxapine (Asendin), Bupropion (Wellbutrin), Doxepin (Sinequan), Nefazodone (Serzone), Trazodone (Desyrel), Trimipramine (Surmontil), Venlafaxine (Effexor) 2. Monoamine oxidase inhibitor (MAOIs) Prevents the breakdown of dopamine, serotonin and norepinephrine Isocarboxacid (marplan), Phenelzine (Nardil), Tranylcypromine (Parnate), moclobemide (Manerix) 3. Selective serotonin reuptake inhibitors (SSRIs) Block reuptake of serotonin at specific serotonin receptor sites Includes Paroxetine (Seroxat, Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox), Fluoxetine (Proxac) Serotonin syndrom may appear in some clients Indicated for depression, OCD, panic disoders Trazodone is the only antidepressant w/o anticholinergic side effects Sedation and tiredness is common Nursing Intervention Assess for the side effects and treat symptomatically Do not give TCAs and SSRIs with or immediately with MAOIs Monitor blood pressure Avoid tyramine-containing foods (aged cheese, wine, pickled and preserved foods and alcohol) may lead to HPN crisis Teach clients to: - Take medications with food - Notify/cosult before taking any other drugs - Not to drive or operate machineries - Advise that these drugs may not take effect until after 2 weeks Antimanic Normalizes reuptake of certain neurotransmitters but exact mechanism is still unknown but there are theories which considers its action on the second messenger system of the body Standard drug of choice is Lithium Carbonate (Quilonium, Eskalith) Effective serum level is 0.5-1.2 meq/L Effect of lithium takes 7-10 days Signs of lithium toxicity - Mild nausea or diarrhea, anorexia, fine hand tremors, polyuria, polydispsia, fatigue and metallic taste In the absence of lithium alternative drugs are: Valporic acid (Depakote) or carbamazepine (Tegretol) Nursing Interventions Remind the client to take the medications regularly Assess drug levels every 3-4 days Monitor salt and fluid intake Teach the client to: - Avoid caffeine

- Take medications with meals For Anticonvulsants - Teach client not to drive until response had been determined - Avoid alcohol and non-prescription drugs - Do not stop the drug abruply Report decreased in urine output Antianxiety Agents Most common drugs are benzodiazepines - Diazepam(Valium), Clonazepam (Klonopin), Lorazepam (Ativan), Triazolam (Halcoin), Chlordiazepoxide (Librium), Clorazepate (Tranxene) Buspirone (Buspar) is the first pure anxiolytic drug and acts as a partial agonist at serotonin receptor sites. It causes no sedation and no dependence Barbiturates may also be used for anxiety such as Phenobarbital but it causes dependence and tolerance Propranolol (Inderal) is a beta-blocker effectively interrups the physiological responses of anxiety Antihistamines Hydroxyzine (Iterax, Atarax) has a central cholinergic effect and is good antianxiety agent Nursing Interventions Caution client to avoid potentially hazardous activities because of draowsiness Warn the client of the danger of concurrent use of alcohol and other CNS depressants Avoid abrupt withdrawal Do not give antacids concurrently Do not take medications with meals Watch for adverse reactions SOMATIC THERAPIES Electroconvulsive Therapy Induction of grand mal seizures through the application of electrical current to the brain to effect behavioral changes Indicated for clients with major depression, acute manic states, schizophrenics (catatonic), OCD and some personality disorders (anti-social) Exact mechanism of actions is still unknown There are no absolute contraindications however relative contraindications include: - Cardiac problems - Increased intracranial pressure - Severe osteoporosis - Acute and chronic pulmonary disorders - Pregnancy The side effects are confusion and temporary memory loss Roles of the nurse in ECT are: Pre - Secure the informed consent - Keep client on NPO at least 4 hrs. prior - Remove dentures, eyeglasses, contact lenses etc. - Client must be asked to void prior - Remain with the client; safety precautions - Encourage client to verbalize feelings - Pre-medications maybe given as ordered (Atropine so4, succinylcholine) Post - Client is oxygenated - An bite block/mouth gag is placed on the client - Provide support to the clients arms and legs during seizures - Turn head to the sides - Monitor vital signs - Stay with the patient until he is fully awake - Reorientation - Provide a highly structured schedule of routine activities to minimize confusion


PSYCHOTHERAPY Goal-oriented corrective emotional experience with a therapies in order to effect behavioral change, including - Increased well being - Improved psychological performance - Improved social performance Usually individual therapy is the most beneficial before a group psychotherapy Treatment maybe longterm, to allow client to gain insight and slowly take on new coping mechanisms Behavioral Therapy Behavioral Modification Altering undesirable behaviors by systematically changing its consequences - Operates on the principle that behavior is determined by consequences - Changes in consequences changes the behavior - Does not deal with the cause of the behavior The process of treatment is: - Identify the behavior to be changed - Obtain baseline data about the behavior - Identify the conditions and reinforcers - Techniques include: * Systemic desensitization; ignoring the behavior; time out; token economy; aversion * Positive reinforcers are preferable to aversion THERAPEUTIC MILEU Milieu Therapy It is the purposeful use of all interactions to assist clients in developing interpersonal and social skills in a conductive physical and emotional environment Manipulates environmental stimuli to provide limits, protect clients and other members of the therapeutic community and promote optimal functioning Activities - Patients government - Self-care activities - Activity therapies * Recreational * Occupational * Creative EVALUATING MENTAL FUNCTIONING Mental Status Examination Standardized nursing assessment procedure aimed at making a diagnosis and determine intervention Designed to determine present mental status ABCs of assessment (appearance, behavior, communication pattern) Assessed according to the ff. mental functions: - Attitude - Sensorium and reasoning - Mood and affect - Potential for danger to self or others - Speech characteristics - Psychological assets - Thought processes Diagnostic Statistical Manual fourth edition (DSM IV) Specific diagnostic criteria developed by the American Psychiatric Association Includes diagnostic criteria and description of each category Important for nurses to be familiar with this system in order to communicate effectively and efficiently with other members of the mental health team Axis I - psychiatric clinical diagnosis Axis II - Presence of mental retardation or personality disorders Axis III General medical conditions Axis IV Psychosocial stressor Axis V - Global assessment of functioning (GAF)


CARE OF THE EMOTIONALLY DISTURBED CLIENTS MOOD DISORDERS Loss and Grieving Denial Anger Bargaining Depression Acceptance Nursing Interventions Provide opportunity for the persons to tell their story Recognize and accept the varied emotions people express in a loss Provide support for the expression of difficult feelings such as anger and sadness Encourage maintain established relationships Acknowledge the usefulness of counseling for especially difficult problems DEPRESSION Abnormal extension and over elaboration of sabness and grief Categories of depression include: - Major depression - Minor depression - Dysthymic disorder Major Depressive Disorder * Five of the ff. present for at least 2 weeks Depressed mood Anhedonia Appetite disturbance with significant change in weight Psychomotor disturbance Sleep disturbance Fatigue or energy loss (anergia) Feelings of worthlessness or excessive or inappropriate guilt Diminished concentration and indecisiveness Recurrent thoughts of death and suicidal thoughts * Causes marked distress and impaired socio-occupational functioning Subgroups of MDD Psychotic depression Melancholic depression Atypical Seasonal affective disorder Other symptoms of depression include: - Apathy - Anger (covert or overt) - Psychomotor agitation - Decreased libido - Ruminations of inadequacy - Spontaneous crying without apparent cause - Dependency - Passiveness Risk Factors Family and personal history of depression Prior suicide attempt Being female Inadequate support systems Life stresses Substance abuse Etiology Biological theories of depression


Genetics play a role in its occurrence Levels of norepinephrine, serotonin and even dopamine are altered; decreased availability in the CNS - Endocrine changes Psychological theories - Object loss theory - Debilitating early life experiences - Aggression towards the self - Intrapsychic conflict - Cognitive theory - Antipsychiatric model - Learned helplessness Escapes from depression Complete hopelessness and inactivity Soliciting or winning sympathy Use of alcohol/substances Frenzied activity Excessive motor activity Suicide Nursing Interventions Maintain clients safety Provide for adequate nutrition, hydration elimination, exercise and physical hygiene Help client have adequate rest and sleep Provide a simple and structured schedule and environment Develop trust Offer sincere concern and empathy Allow and encourage verbalization of feelings Bolster self-esteem - Accept patients where they are and focus on their strengths - Point out even small accomplishments - Reinforce decision making by patients - Redirect clients conversation away from self-reproach and derogation - Involve patients in activities in which they can experience success - Respond to anger therapeutically Recognize dependence - Make decisions for patients that they are not ready to make for themselves Spend time with withdrawn patients Encourage increasing participation in social, recreational and occupational activities Never reinforce delusions or hallucinations BIPOLAR DISORDERS Individuals experience extremes in mood polarity Manic-depressive Mania is a distinct period of abnormal and persistent elevated, expansive or irritable mood in which a person is extraordinarily energic. MANIC EPISODES Inflated self-esteem or grandiosity Decreased need for sleep Very talkative (Pressured speech) Flight or ideas or subjective feeling that thoughts are racing Reduced ability to filter out external stimuli; easily distractible Increased number of activities with increased energy and psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for personal problems (sexual promiscuity, spending sprees etc.) - Uses poor judgement with severe consequences Lasts at least one week and severe enough to cause problems; not due to a substance Etiology Psychodynamic theories - Mania as a defense or a mask of depression


- Developmental: Mistrust and dependence Biological theories - Genetics is influential in bipolar disorders - Excessive levels of neurotransmitters Nursing Interventions Provide for patients physical safety and safety of those around him Remind the client to respect distances between self and others Use short simple sentences to communicate Ask the clients to clear their messages and to decode metaphors, themes and symbols used in speech Provide the clients with a list of daily activities Ensure that food and fluid needs are met For patients too busy to eat - Provide patients with foods that can be eaten on the run (finger foods) because patients cannot sit ling enough to eat - Provide high-protein, high calorie snacks - Weight patients regularly Reduce stimulation from the environment and others - A quiet room maybe indicated to decreased environmental stimuli - Remain quietly with the client rather than encouraging activities and conversations Channel clients need for movement into socially acceptable motor activities - Goal-oriented activities are encourage - Competitive sports activities are not allowed initially - Mental activities will not be done by patients

SUICIDAL CLIENTS SUICIDE Direct self-destructive behavior; self-inflicted death Influenced by a persons cultural beliefs, values and norms Never a random act, whether done impulsively or with painstaking consideration, the act has both a message and a purpose 4 times more common in men More common in white persons and least common in black persons Common among schizophrenics, depressed and alcoholic patients More common in spring More likely to occur in the early morning hours Levels of suicidal behavior Suicidal gestures - non-lethal, self-injurious acts done to get attention Suicidal ideations thoughts of suicide Suicidal threats verbal statements Suicidal attempt actual implementation Completed suicide warning signs have been missed/ignored Common expressions of suicidal patients Cry for help - redemption Escape - relief of pain Heroism - retaliatory Loss of self-esteem - reunion Manipulation Martyrdom Rebirth Risk Factors * General medical illness * Living alone * Severe anhedonia * Age 60 and above * Male * Unemployed and financial problems * Caucasians and Native Americans * Prior suicide attempts


Etiology Psychodynamic Theories - Instinct for life vs. instinct for death - Aggression towards the self - 3 Ps Pain, perturbation and pressure Sociological Theories - Social and cultural contexts influence ideations of suicide Biological Theories - There is decreased serotonin and its metabolites in patients who are suicidal Predisposing Factors Include: - Psychiatric disorders (mood, substance, psychotic disorders) - Personality traits (hostility, impulsivity, chronic depression) Nursing Intervention Evaluate patients for suicidal risk - Note behaviors like making a will, saying goodbyes and giving away prized possessions Suspect suicidal ideation in the depressed Inquire directly about frequency and content of suicidal ideation Ask patients about the advantages and disadvantages of suicide Evaluate the patients access to means of suicide Develop a formal no suicide contract with patients Monitor closely and continuously Advise patients to discontinue drugs and /or alcohol Reduce the desire to attempt suicide Encourage verbalization of feelings Support patients reason to live

SCHIZOPHRENIA Withdrawn Behavior Aretreat from interactions with people and environment to avoid facing important social obligations Examples of unhealthy use of withdrawal: - Excessive fantasizing - Excessive involvement in solitary activities In extreme situations, the person may retreat from reality Schizophrenia Characterized by a deteriorating personality Four As of schizophrenia 1. Affective disturbances inappropriate 2. Autism preoccupation with the self with little concern for external reality 3. Associative looseness string unrelated topics 4. Ambivalence simultaneous opposing feelings Occurs in the late adolescence and early adulthood More common in lower socio-economic groups High prevalence among family members and in twins Criteria of Schizophrenia At least two characteristic symptoms - Delusions - Grossly disorganized or catatonic behavior - Hallucinations - Negative symptoms - Disorganized speech Social and occupational dysfunction and deterioration Continuous sign of the disturbance for at least 6 months (schizophreneform if not) Schizoaffective and mood disorders are not present and is not responsible for symptoms Not caused by substance abuse or a general medical condition Disturbance in Thinking * Delusions * Neologisms


* Looseness of association * Blocking * Concrete thinking * Magical thinking Disturbance in sensory perception Disturbance in affect Disturbance in interpersonal relationships Subtypes Paranoid Schizophrenia - Preoccupation with one or more delusions or with frequent auditory hallucinations Disorganized Schizophrenia - Disorganized speech, behavior, affective disturbance are prominent - Previously termed hebephrenia Catatonic Schizophrenia - At least two of the following are present: * Motoric immobility, waxy flexibility, or stupor * Excessive motor activity (purposeless) * Extreme negativism or mutism Undifferentiated Schizophrenia - Characteristic symptoms are not present but criteria for the other subtypes have not been met Residual Schizophrenia - Characteristic symptoms may no longer be present - There is continuing evidence of disturbance such as the presence of a negative symptoms or positive symptoms in attenuated form (odd beliefs, unusual perceptual experiences) Etiology Biological Theories - Genetic component is present - Dopamine hypothesis excessive dopaminergic activities in the cortical areas causes acute psychotic symptoms - Neurostructural changes Developmental Theories - Impaired interpersonal relationship with primary caregiver - Poor ego boundaries, fragile ego and ego disintegration Family Theories - Schizophrenic mother - Double-bind Vulnerability-Stress Model - Recognizes both biological and psychodynamic Nursing Intervention General Principles for a therapeutic relationship - Be calm when talking to patients - Accept patient as they are but do nut accept all behavior - Keep all promises - Be consistent - Be honest Maintain a safe and therapeutic environment Meet the patients physiologic needs Help patient maintain contact with reality - Orient the patients to time and place if indicated Reduce hallucinations and delusions - Present reality without arguing - Engage in conversations that are simple, direct, specific and concrete - Do not dwell on the content of delusions Decreased withdrawal - Engage in one relationships as tolerated by clients - Engage in social activities - Allow interpersonal distance if necessary - Do not touch the patients without warning them - Avoid whispering or laughing when patients are unable to hear all of a conversation - Avoid competitive activities with some patients Encourage differentiation of self from others and the environment


Allow and encourage verbalization of feelings Increased the clients self-esteem - Provide opportunities to be successful - Convey an attitude of respect - Do not embarrass patients - Reinforce positive behaviors - Encourage participation in self-care activities CARE OF THE ANXIOUS CLIENTS ANXIETY DISORDERS Anxiety usually predominates and the person is usually in a state of conflict Persistent or recurrent Certain defense mechanism are used repeatedly in an attempt to control anxiety Anxiety maybe present despite the absence of triggers Creates a significant impairment in socio occupational functioning Primary gain refers to the individuals desire to relieve anxiety in order to feel better and more secure Secondary gain refers to the attention and support the individual derives from others because of illness Generalized Anxiety Disorder Excessive worry and anxiety Difficulty in controlling the worry Anxiety and worry is evident in - restlessness, fatigue and irritability, diminished concentration, muscle tension, disturbed sleep Chronic feelings of nervousness and apprehension for no apparent reason PANIC DISORDERS Recurrent, unexpected panic attacks followed by a month or more of worry about having additional attacks, worry about the results of the attacks, and behavioral changes related to the attacks May have Agoraphobia - Fear of being in public places wherein escape may be difficult; fear of the fear OBSESSIVE-COMPULSIVE DISORDER Obsessions are intrusive, inappropriate, recurrent and persistent thoughts, impulses or images that are distressful and produce anxiety Unsuccessful attempts to ignore or neutralized thoughts or impulses by other thoughts or actions Trivial or ridiculous; often morbid and fearful Compulsions are uncontrollable, persistent urge to perform certain acts repetitively to relieve an otherwise unbearable tension There is a recognition that obsessions or compulsions are unreasonable and excessive but they cannot sem to stop Obsessions or compulsions causes distress, are time-consuming and interfere with daily activities PHOBIC DISORDERS Phobia is a persistent and irrational fear of a specific object, activity or situation that results in a compelling desire to avoid the dreaded object or situation The fear is recognized as excessive and unreasonable in proportion to the actual danger Maybe primary or secondary Categorized into - Agoraphobia - Social phobia - Specific phobia/simple phobia ACUTE STRESS DISORDERS Exposure to a traumatic event involving threat of death/injury to self or others, or actual injury to self and others Responses of horror, helplessness and fear Dissociative symptoms immediately after


Avoidance of stimuli related to trauma Increased arousal or anxiety - Sleep disturbance, hypervigilance, easy startle Re-experiencing or relieving the traumatic event - distressing thoughts dreams Impairment in socio-occupational functioning Onset is within 4 weeks after the event and the duration is between 2 days to 4 weeks POSTTRAUMATIC STRESS DISORDER Same as that of ASD Numbing of responsiveness - Inability to recall aspects of the event - Restricted affect - Sense of foreshortened future Survivor guilt Occurs within 6 months after the event or even more (delayed) Nursing Interventions To reduce anxiety - Provide a calm and quit environment - Ask patients to identify what and how they feel - Encourage the patients to discuss feelings - Help patients identify possible causes of their feelings - Listen carefully for patients expressions of helplessness and hopelessness - Plan and involve patients in activities such as walking or playing recreational games - Encourage verbalization of feelings and explore anxiety provoking situations - Explore solutions For panic - Remain with the client and provide safety - Reduce environmental stimuli and approach always in a calm manner - Focus clients attention on a simple, repetitive task For ritualistic behaviors - Avoid interfering with the ritual - Set rational limits on ritualistic behavior in terms of timing frequency and location - Structure simple activities or task for patients - Encourage to participate in activities where clients can attain control and success - Recognize and reinforce non ritualistic behaviors For ASD and PTSD - Acknowledge any unfairness or injustice related to trauma - Assure them that their feelings and reaction are typical reactions to serious trauma - Encourage safe verbalizations of feelings especially anger - Encourage adaptive coping strategies, exercise, relaxation techniques and sleeppromoting strategies - Facilitate progressive review of the trauma and its consequences - Encourage the patients to establish or re-establish relationship PSYCHOPHYSIOLOGIC DISORDER Medical condition precipitated by a psychological conflict With actual tissue damage and injury Organic basis present PUD, HPN, ulcerative colitis, migraine etc. SOMATOFORM DISORDERS Involves physical symptoms without any organic or physiologic cause Not under voluntary control Symbolizes repressed and unresolved conflicts SOMATIZATION DISORDER Chronic somatic complaints of long-duration


Complaints changes from one anatomic site to another A complicated medical history is common PAIN DISORDER Prolonged and severe pain that seem unrelated to physical causes Seems to correlate with psychological stress Pain is usually localized in one anatomic site May present with abuse of analgesics CONVERSION DISORDER Loss of sensory or motor functioning that seems unrelated to physical cause Neurologic problems are common The physical problem is symbolic of underlying anxiety Presence of la belle indifference HYPOCHONDRIASIS Fear of serious illness despite reassurance to the contrary Preoccupational with the belief that a serious illness is present and may interfere with daily life Physical signs and symptoms are consistently misinterpreted to mean that the clients is ill BODY DYSMORPHIC DISORDER Preoccupation with some imagined defect in physical appearance which is out of proportion to any actual abnormality Nursing Interventions Avoid reinforcing the symptoms - do not focus on them to reduced secondary gain - Do not attempt to persuade the client that the symptoms are not real or that the client should give it up Increase self esteem by involving clients in activities in which they can be successful Encourage to identify and explore feelings DISSOCIATIVE DISORDERS Sudden temporary change in consciousness, identity or motor behaviors The repression of ideas that leads to amnesia and other forms of dissociation is conceived as a way of protecting the individual from emotional pain Types of dissociative disorders Dissociative Amnesia - Loss of memory of important personal events that were traumatic or stressful in nature - Inability to recall personal information Dissiociative fugue - Sudden unexpected travel away from home or work with loss of memory about the past - Assumption of partial/completely new identity Depersonalization - Expresses feelings of detachment from or an outside observer of ones body or mental processes - Unreality or self-estranger (derealization) Nursing Interventions Reduce external stress and demands on the client Present reality Reassure the client that memory will return Encourage to explore and verbalize feelings Set rational limits on behavior Assist in the exploration or preceding event Reduce the clients anxiety AGGRESSIVE BEHAIORS Phases of the Aggressive Cycle Triggering phase Escalation phase Crisis phase


Recovery phase Post crisis phase Nursing Interventions Nurse should approach the client in a non-threatening way Provide directions for the client in calm firm voice Advice the client to take time-out for cooling Show of force Provide a safe environment for patient and others Planned team approach is best May use mattress approach Restraints may be used or applied if needed Encourage the client to explore alternatives to aggressive behaviors Show empathy Encourage continued verbalizations of feelings SUBSTANCE RELATED DISORDERS Substance Abuse * Pattern of pathologic use - Inability to cut or stop use despite physical disorder known to be increased by its use and despite the presence of complications - Usually intoxicated throughout the day - Required daily to function * Impairment in functioning Legal difficulties and failure in obligations Behavioral changes Substance dependence - Tolerance - Withdrawal Etiology Psychoanalytic/Psychodynamic - fixation or regression to the oral stage of development Sociological - Learned behavior encouraged by a subculture in which drugs are easily available and its use is encouraged Biochemical - Physiologic dependence; readdiction or craving ALCOHOLISM Alcohol Genetic predisposition Usually appears between the ages 20-40 however becoming common in adolescents More common in men than in women Chronic use leads to Wernickes-Korsakoff syndrome Signs of drug abuse Sudden loss of interest or deterioration in school work fand other activities Dropping old friends and associating with a new peer group Secretive behaviors; spends a lot of time alone Sudden and unexplained changes in mood, emotion and behavior Physical signs such as pupil changes, slurred speech, needle marks, photophobia etc. - One must determine drugs use pattern of the client from information provided by the client, famity and friends 1. Drugs being used 2. Quantity 3. Frequency 4. Length of use Analysis of blood and urine for substances Drug Abuse CNS depressants (downers) - benzodiazepines


Psychostimulants - Cocaine Hallucinogens - Cannabinoids: Marijuana - Psychedelics: PCP, LSD Inhalants Narcotic/Opoids - Heroin Nursing Interventions Detoxication phase - Encourage participation in a treatment program and refer to appropriate treatment resources - Support the client through the detoxication or withdrawal - Detoxication may take 2-3 weeks and should take place in an in-patient setting - Attend to clients physical problems Rehabilitative phase - Assist clients to identify the stresses and conflicts and encourage exploration of alternative coping strategies - Assist the client to identify social support network - Provide support to significant others - Provide health teachings to clients PERSONALITY DISORDERS Disorders characterized by deeply ingrained, maladaptive behavioral patterns that are life-long in duration Inflexible and disruptive personality traits and lifestyles that impair socio-occupational functioning They are eg-syntonic Begin in childhood or adolescence and persist throughout adult life It is difficult to form and maintain satisfying interpersonal relationships Clusters of Personality disorders Cluster A Personality disorders - Odd and eccentric - Paranoid, schizoid and schizotypal Cluster B personality disorders - Dramatic, emotional and erratic - Borderline, antisocial, histrionic and narcissistic Cluster C personality disorder - Fearful and anxious - Obsessive-compulsive, avoidant and dependent PARANOID PERSONALITY DISORDER Pervasive, unwarranted suspiciousness and mistrust; jealousy, envy, guardedness Hypersensitive and feels mistreated and misjudged Restricted feelings; lacks of sense of humor Absence of sentimental, tender feelings Pride in being cold and unemotional SCHIZOID PERSONALITY DISORDER Emotional coldness and aloofness Indifference to praise or criticism from others Tendency to be reserved and seclusive No desire for social involvement SCHIZOTYPAL PERSONALITY DISORDER Presence of various oddities of thought, perception, speech and behavior such as ideas of reference, bizarre fantasies and preoccupations Hypersensitive with suspiciousness to real or imagined criticism Social isolation is common BORDERLINE PERSONALITY DISORDER


Impulsive and unpredictable in areas of life that are self-demanding A pattern of unstable but intense interpersonal relationship Inappropriate displays of temper Mood instability Uncertainty about identity Intolerance to being alone Physically self-damaging Chronic feelings of emptiness and/or boredom Requires hospitalization because of suicidal tendencies

ANTISOCIAL PERSONALITY DISORDER Total disregard for the rights of other people Behaviors are in conflict with society such as theft, vandalism and other crimes Failure to exhibit lawful behavior Tendency not to feel guilt, learn from experience and blame others Lack of ability to function as a responsible individual Inability to delay gratification and may become hostile because of frustrations Unable to maintain enduring attachment to sexual partner HISTRIONIC PERSONALITY DISORDER Behavior that is overly dramatic, erratic and intense Engages in attention-seeking, self dramatization and irrational outbursts of emotions Perceived by others as shallow, self-indulgent and vain Prone to manipulate threats and gestures NARCISSISTIC PERSONALITY DISORDER Grandiose sense of self-importance Preoccupied with fantacies of success, wealth and power, beauty and brilliance Need for attention and admiration Indifference to criticism Expects special favors, takes advantage of others Lacks ability for empathy OBSESSIVE-COMPULSIVE PERSONALITY DISORDER Overconscientious, overmeticulous, perfectionistic Excessive concern for conformity Rigid adherence to strict standards Restricted ability to show warn and tender emotions Preoccupation with trivial details AVOIDANT PERSONALITY DISORDER Hypersensitive to rejection and interpretation of innocuous events as ridicule Unwillingness to become involved with others Social withdrawal in interpersonal and works roles Desire for affection and acceptance DEPENDENT PERSONALITY DISORDER Passively allows others to assume responsibility in major areas of ones life Subordinates own needs to those whom clients depend on Does not want to rely on self Lacks self-confidence Management: Long-term psychotherapy Anti-anxiety agents Electroconvulsive therapy Nursing Interventions: Increase the clients ego strength through positive reinforcement and feedback - Provide rewards for behaviors which are consonant with social norms and expectations - Encourage and support the unique qualities of a person - Acknowledge the clients achievements however small Help the client expand his repertoire of coping behaviors


- assist in identifying and analyzing coping strategies - Assist clients explore alternative behaviors Implement strategies for reducing anxieties Set firm, rational limits making sure that the client is aware of expectations Encourage client to identify the effects of his/her behaviors on others Assist clients in becoming assertive rather than passive or aggressive

SEXUAL DISORDERS Sexual dysfunctions Inhibition of the sexual appetite or psycho-physiological changes that compromise the sexual response cycle The sexual response cycle: - Phase 1: Appetitive - Phase 2: Excitement - Phase 3: Plateau Types of Sexual Dysfunction Sexual desire disorder - Hypoactive - Sexual aversion disorder Sexual arousal disorder Orgasmic disorder - Premature ejaculation - Anorgasmia Sexual pain disorders - Dyspareunia - Vaginismus Predisposing factors - Biological - Psychosocial - Relationship factors Phase 4: Orgasm Phase 5: Resolution

Paraphilias (sexual perversions) Sexual instinct is expressed in ways that are socially unacceptable and is prohibited Peaks between the age of 15 and 25 and decrease in incidence by age Always enters the cycle of sexual perversion Types * Exhibitionism * Voyeurism * Frotteurism * Bestiality * Pedophilia * Necrophilia * Incest * Telephonic scatologia * Sexual masochism * Coprophilia * Sexual sadism * Pyromania * Fetishism * Nymphomania and satyriasis Gender Identity Disorder Homosexuality Bisexuality Transexualism (gender dysphoric disorder) EATING DISORDERS ANOREXIA NERVOSA Profound disturbance in body image and a relentless pursuit of thinness often to the point of starvation Weight phobia Common in females 10-30 y/o Refusal to maintain body weight at a normal BMI or it is less than 85% of the DBW Disturbance in the way in which ones body weight or shape is experienced - self evaluation is based on body weight but is always in denial - Amenorrhea (at least 3 consecutive cycles)


Other clinical features - Most aberrant behaviors directed towards losing weight are in secret - Refusal to eat with families or in public places - Drastic reduction in total food intake with disproportionate decrease in high carbohydrate and fatty foods - There is actual preoccupation with food - There are peculiar behaviors regarding food - Associated with obsessive-compulsive behaviors, depression and anxiety - Markedly decreased interest in sex - Overall prognosis is not good though some will spontaneous recovery Types Restricting type Binge eating/purging type Etiology Biological - Decreased serotonin in CNS - Presence of endogenous opiates for denial of hunger Socio-cultural - Society is focused on thinness and exercise - More common in females - Most frequent in developed countries Common in professions such as modeling and ballet Psychological - Reaction to the demands for more independence in increased social and sexual functioning - There is lack of autonomy and selfhood - Acts of extraordinary self-discipline - Intrusive and unempathetic mother model Physiologic symptoms Hypothermia Edema Bradycardia Hypersensitivity Hypotension Lanugo Treatment Hospitalizations Individual (Weight-oriented) Family therapy Medications - Amitriptyline (Elavil) - Cyproheptadine (Periactin) Nursing Interventions Monitor caloric intake Watch out signs of purging Weigh daily Monitor activities Plan for a realistic and healthy diet Monitor nutritional and electrolyte status For anorexia nervosa - Increasing self-esteem is a primary objective - Listen empathetically - Engage clients in the food planning process - Help identity and express bodily sensations - Identify non-weight related interest - Improve social skills BULIMIA NERCOSA Consist of recurrent episodes of eating large amounts of food accompanied by a feeling of out of control


There are feelings of guilt, depression and self-disgust after There are recurrent compensatory behaviors: purging, fasting or excessive exercise They maintain normal body weight Etiology Biological - Endorphin levels are increased Psychological - Parents maybe rejecting and neglectful - Difficulties with adolescent demands - Anorexics lacks ego strength while bulimic lacks superego control Types Purging Non-purging Treatment Individual psychotherapy Antidepressants - Imipramine (Tofranil) - Fluoxetine (prozac) Nursing Interventions For binge eating - Create an atmosphere of trust - Identify feeling associated with binging/purging behavior - Improve self-esteem - Teach about eating disorders - Explore interpersonal relationships MENTAL ILLNESS IN THE ELDERLY Cognitive disorders DELIRUIM Disturbance in consciousness accompanied by a change in cognition Characterized by an acute onset and may last from hours to a number of days It is potentially reversible but can be life-threatening if not treated Secondary either to a general medical condition or to effects of substances Features Altered psychomotor activity such as apathy, withdrawal or agitation Bizarre destructive behavior worsening at night (Sun downing Phenomenon) Disorganized thinking and disorientation Distractibility and inability to complete tasks Impaired decision making Poor impulse control Rambling, bizarre or incoherent speech Tremors and generalized seizures Visual and auditory illusions Nursing Intervention Determine the degree of cognitive impairment Create a structured and safe environment Institute measures to help patient relax and fall asleep Keep the room lit to allay fears and prevent visual hallucinations Monitor effects of medications DEMENTIA Altered mental state secondary to a cerebral disease Usually irreversible, gradual in onset, progressive, degenerative Characterized by a decreased intellectual function, personality change, impaired judgement and often change in affect Impairment in functioning is present


Multiple cognitive deficits Anemia - Memory impairment Aphasia - Language disturbance Apraxia - inability to carry out motor activities despite intact motor functioning Agnosia - Failure to recognize or identify objects despite intact sensory function Disturbance in executive functioning - planning, organizing, sequencing, abstracting ALZHEIMERS DIEASE Major cause of dementia in the elderly Unknown etiology but some theories include - Alterations in acetylcholine Very strong genetic predisposition Organic changes occur - Brain atrophy, widening of sulcus and ventricles - Neurofibrillary tangles and amyloid bodies Stage 1 Agitated or apathetic mood Attempts to cover up symptoms Decline in personal appearance Decline in recent memory Decreased concentration Depression Disorientation regarding time Disturbed sleep Inability to retain new memories Susceptibility to falls Transitory delusions of persecutions Wandering Stage II May last from 2-12 years - Confabulation (unconscious filling of memory gaps with fabricated facts and experiences) - Ontinuous repetitive behaviors - Diminishing ability to understand or use language - Disorientation to person, place and time - Hoarding - Inability to recognize family members - Inability to retain new information - Incontinence of bowel and bladder - Increased appetite with no weight gain - Requiring assistance with ADL - Socially unacceptable behavior - Tantrums Stage III Compulsive touching and examination of objects Decreased response to stimuli Deterioration in motor abilities Emaciation Non responsiveness Severe decline in cognitive functions Terminal stage (months to 5 years) Drug therapy


Anti cholinesterase agents - Tacrine (Cognex), Denazepil (Aricept) Antipsychotic agents - in low doses like haloperidol or risperidone Benzodiazepines - Aprazolam (Xanax), Diazepam (Valium) Nursing Interventions Remove any hazardous items or potential obstacles from the patients environment to provide and maintain safety Monitor food and fluid intake Provide verbal and non-verbal communication that is consistent and structured State expectations simply and completely Increase social interaction to provide stimulus for the patients Encourage the use of community resources Promote physical activity and sensory stimulations - Dizziness, emotional liability - Inappropriate emotional reactions - Memory loss - Neurologic symptoms that may last only a few days - Rapid onset of symptoms - Slurred speech - Wandering and getting loss in familiar places - Weakness in the extremities Nursing Interventions Orient the patient to his surroundings Monitor the environment Encourage the patient to express feelings MENTAL DISEASES IN CHILDREN Mental illness in the children and adolescents Children are less able to verbalize feelings Irritability maybe a predominant feature Risk factors for childhood psychiatric disorders are - Genetic and biological factors - Adverse environmental influences - Family and socio-cultural factors - Stress experience - Children can be motivated by their peers - Negative effects of risk factors depend upon the severity of the risk and the resiliency of the child - Resilience is the ability to withstand problems of an undesirable childhood MENTAL RETARDATION Below average intellectual functioning and impairment in adaptive skills that is present before 18 years old Arrested or incomplete development of the mind Classified according to severity Mild IQ level 50-55 to approximately 70 Moderate IQ level 35-40 to 50-55 Severe IQ level 20-25 to 35-40 Profound IQ below 20 or 25 Etiology Chromosomal abnormalities Genetic factors Prenatal Factors Prenatal substance exposure Complications of pregnancy Perinatal factors


Acquired childhood disorders AUTISTIC DISORDER Disturbance in social relatedness Common features - Delayed socialization and communication - Stereotypical behaviors - Peculiar preoccupations Early age onset (before 30 months) Substantial percentage are mentally related ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) Most common pediatric psychiatric disorder Inattention - Inattentive to detail - Difficulties with organizing tasks - Difficulty sustaining attention - Often loses things - Not listening to what is being said - Is often easily distracted - Poor follow through on instructions - Is often forgetful in daily activities Hyperactivity-impulsivity - Fidgety - Often has difficulty waiting in line or turns - Inappropriately leaves seat - Inappropriate running or climbing - Difficulty in playing quietly - Blurts answers to questions The onset is not later than 7 years of age Treatment is through - Psychostimulants - Methylphenidate (Ritalin) - Pemoline (Cylert) - The Feingold diet elimination of artificial flavoring and colorings and natural salicylates in food OTHER CHILDHOOD DISORDERS Pervasive developmental disorders Disruptive disorders Learning disorders Communication disorders Tic disorders; Tourettes Syndrome Elimination disorders The nurses role in childhood mental disorders Help the parents accept a diagnosis and plan a realistic approach to the situation Help shape family members and other peoples attitudes towards them and accept them Help in activities of daily living Standards of acceptable behavior within the ability of the child should be provided He should b taught to seek help when in difficulty to resist frustration and achieve emotional control Create a therapeutic environment CARE OF THE CAREGIVER Role Strain When the demands of providing care threaten to overwhelm the caregiver Characterized by: - Constant fatigue unrelieved by rest - Use of alcohol/other substances - Social isolation - Inattention to personal needs - Inability/unwillingness to be helped by others It may become a factor in the neglect or abuse of patients Nursing Interventions Refer caregivers to knowledgeable health professional who can provide information, support and assistance


Provide outlets for dealing with caregivers feelings Help them seek and accept assistance from other people or agency and not wait until they are exhausted Provide support for a personal life VICTIMS OF ABUSE AND VIOLENCE Phases of Trauma Impact phase - shock, denial, disbelief, confusion and initial disorganization Recoil phase - Struggle to adapt, presence of a persistent emotional stress Reorganization - Reconstruction of ones life and regaining a sense of control and self protection RAPE AND SEXUAL ASSULT Rape is the forcible penile penetration of a victims body without consent while sexual assault is any other form of forced sexual contact Rape is not sexually motivated but involves a desire for power and control and a wish to humiliate the victim Typical reaction is a retreat to safe place Rape and Trauma Syndrome Sleep disturbance, nightmares Loss of appetite Fear, anxieties, phobias and suspicions Decreased activities and motivation Disturbance in relationships Self-blame, guilt and shame Lowered self-esteem, worthlessness Somatic symptoms Nursing Interventions Reaffirm that they are worthwhile persons with dignity and rights, who is not cause and deserve the rape Convey to them that their anger is natural Move at the victims pace and be supportive Always give rationales and descriptions for any procedures Protect the patients rights Partner Abuse; Domestic Violence Maybe physical, psychological or other violations of rights Most abusers are substance users as well Women describes abusers as having changing personalities In some relationships, violence is mutual There is development of learned helplessness, hopelessness, isolation and resignation Cycle of Domestic Violence Abuse is not constant nor it is random There is an imbalance of power in a relationship It occurs in three phases: 1. Tension building 2. Serious battering incident 3. Honeymoon * The last phase is what convinces the partner to stay in the relationship Nursing Interventions Identify the abusers behavior as abusive and acknowledge the seriousness of the abuse Give the victim a list of resources Tell the abuser to stop the abuse and get help Welcome to the Psychiatric Hotline If you are obsessive-compulsive, please press 1 repeatedly If you are co-dependent, please ask someone to press 2 If you have multiple personalities, please press 3,4,5 and 6


If you are paranoid-delusional, we know who you are and what you want. Just stay on the line so we can trace the call. If you are schizophrenic, listen carefully and little voice will tell you which number to press If you are depressed, it doesnt matter which number you press. No one will answer If you are delusional and occasional and occasionally hallucinate, please be aware that the thing you are holding on the side of your head is alive and about to bite off your ear. NOTE: These are supplemental handouts only. We still advice you to have additional readings as necessary